Chibanda et al.

BMC Psychiatry (2016) 16:55

DOI 10.1186/s12888-016-0764-2

RESEARCH ARTICLE Open Access

Prevalence and correlates of probable

common mental disorders in a population
with high prevalence of HIV in Zimbabwe
Dixon Chibanda1*, Frances Cowan2, Lorna Gibson3, Helen A. Weiss3 and Crick Lund4

Abstract
Background: In 2014 close to 10 million people living with HIV (PLWH) in sub-Saharan Africa were on highly active
anti-retroviral therapy (HAART). The incidence of non-communicable diseases has increased markedly in PLWH as
mortality is reduced due to use of HAART. Common mental disorders (CMD) are highly prevalent in PLWH. We
aimed to determine factors associated with probable CMD and depression, assessed by 2 locally validated screening
tools in a population with high prevalence of HIV in Harare, Zimbabwe.
Methods: We carried out a cross-sectional survey of a systematic random sample of patients utilizing the largest
primary health care facility in Harare. Adults aged ≥18 years attending over a 2-week period were eligible, excluding
those who were critically ill or unable to give written informed consent. Two locally validated screening tools the
Shona symptom questionnaire (SSQ-14) and the Patient Health Questionnaire (PHQ-9) were administered by trained
research assistants to identify probable CMD and depression.
Results: Of the 264 participants, 165 (62.5 %) were PLWH, and 92 % of these were on HAART. The prevalence of probable
CMD (SSQ14 > = 9) and depression (PHQ9 > = 11) were higher among people living with HIV than among those without
HIV (67.9 and 68.5 % vs 51.4 and 47.2 % respectively). Multivariable analysis showed female gender and recent negative
life events to be associated with probable CMD and depression among PLWH (gender: OR = 2.32 95 % CI:1.07–5.05;
negative life events: OR = 4.14; 95 % CI 1.17–14.49) and with depression (gender: OR = 1.84 95 % CI:0.85–4.02; negative life
events: OR = 4.93.; 95 % CI 1.31–18.50)
Conclusion: Elevated scores on self-report measures for CMD and depression are highly prevalent in this high HIV
prevalence population. There is need to integrate packages of care for CMD and depression in existing primary health
care programs for HIV/AIDS.
Keywords: Common mental disorders, Depression, HIV, Highly active antiretroviral therapy

Background where low levels of CMD detection at primary health care

Common mental disorders (CMD) affect people across level [10] are confounded by a large treatment gap for
the world with a global lifetime prevalence of 29 % [1]. CMD [11, 12]. In sub-Saharan Africa it is estimated that
Presenting as a mixture of somatic, anxiety, and depressive there is one psychologist for every 2.5 million people, one
symptoms [2], CMD increase the risk of developing both mental health nurse for every million people and one
non-communicable and communicable diseases [3]. psychiatrist for every 2 million people [13]. In contrast, in
Amongst people living with HIV (PLWH), CMD are a high income countries the ratio of psychiatrists to the
leading cause of disability [4–7] and are known to hasten population is estimated to be 1:10000 [14].
HIV disease progression [8], particularly in LMIC [4, 6, 9] In recent years the development of interventions that
emphasize task-shifting as a way to address the treatment
gap for CMD has gained recognition [15–18] with specific
* Correspondence: [email protected]
1
University of Zimbabwe, College of Health Sciences, Mazowe Street, P.O Box
structured packages being developed and evaluated
A178, Harare, Zimbabwe [19–21]. The key elements of task-shifting involve the
Full list of author information is available at the end of the article

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Chibanda et al. BMC Psychiatry (2016) 16:55 Page 2 of 9

delegation of responsibilities to lower level cadres, often The primary health facility, which runs a daily HIV clinic,
non-professionals, to deliver services while the more focuses mainly on prescribing ART and treating other HIV-
qualified professionals provide support and supervision related conditions, whilst also catering for both adults and
[22]. However, use of targeted task-shifting psychological children with non-HIV related conditions. All adults
interventions to address CMD in PLWH requires a thor- aged ≥18 years presenting to the clinic during the 2-
ough understanding of factors associated with CMD in this week study period from 14th-30th October 2013 were
population [4, 23], due partially to the need for greater eligible for recruitment. Patients were excluded if they
monitoring and supervision of work delivered by non- were critically ill (being physically incapacitated), had a
specialists [24–26]. psychotic episode at presentation, or were unable to
Much is known about factors associated with CMD in comprehend the consenting procedure or declined to
non-HIV populations in LMIC [27–31], contrasting with give written informed consent.
sparse data on CMD among PLWH [6]. In four LMIC,
namely India, Zimbabwe, Chile and Brazil, female gender, Study procedure
poverty and recent life events were found to be common Study personnel (four research assistants, six LHWs and
correlates of CMD in non-HIV populations [29]. In other four psychiatrists) attended a 2-week training using a
parts of the world, correlates of CMD in PLWH include guide initially developed by the author (DC). The research
death of a significant other [32], family history of mental ill- assistants were trained on data collection methods using
ness, negative coping style, alcohol dependency, food inse- the socio-demographic forms and the screening tools.
curity [33] and recent negative life events [34, 35]. Other While the project coordinators were trained in screening
studies from poor resource settings have found that CMD of participants to minimize bias. The psychiatrists were
in PLWH is correlated with trauma, posttraumatic stress trained in the use of the structured clinical interview
disorder (PTSD), stigma and social barriers such as peoples’ (SCID-IV) through a discussion forum led by DC which
attitudes towards disabilities, physical and organizational involved going through the diagnostic criteria, building
obstacles, however, these differences appear to be due consensus on how to manage clinically severe cases dur-
to a difference in the study setting and study population ing the validation, and procedures for ensuring fidelity.
[36–39]. The referral pathways for participants meeting criteria for
Early studies of CMD in PLWH in Zimbabwe were major depression and other acute medical conditions was
based on antiretroviral (ART) -naïve populations using that they should be seen by the medical officer first, for as-
the Shona Symptom Questionnaire (SSQ-14) [40] as the sessment, before being referred to a tertiary psychiatric
main outcome instrument. Findings were inconsistent, facility if needed. A 2-day pilot of the full study procedure
with correlates of CMD including being female, having a was carried out after training of the entire study team.
male partner who was older by 10 or more years, multi-
parity (having borne a number of children), and negative Ethical considerations
life events [34, 41, 42]. Ethical approval was obtained from the Medical Research
The aim of this study was to determine the prevalence Council of Zimbabwe (MRCZ/A/1732), and the Human
and correlates of probable CMD in a primary health care Research Ethics Committee of the Faculty of Health Sci-
setting with a high prevalence of HIV, and to compare ences, University of Cape Town (HREC Ref: 090/2014) and
these correlates of CMD by HIV status. The study was part the London School of Hygiene and Tropical Medicine (Ref
of the validation of screening tools for CMD in a popula- 8457), and written informed consent was sought from all
tion with a high prevalence of HIV, which was preparatory participants in accordance with good clinical practice. All
work for a randomized controlled trial of a psychological participants requiring immediate attention due to severe
intervention to reduce depression. The trial used the SSQ- CMD were referred to an existing service for people with
14 and the 9-item Patient Health Questionnaire (PHQ-9) psychological distress based on problem solving therapy
as primary and secondary outcome measures respectively. running at the clinic [44].
Establishing the prevalence of CMD among primary health
care patients helped determine the possible duration of re- Recruitment and sample size
cruitment of participants for the trial, and analysis of corre- The clinic register of clients attending the clinic over the
lates of CMD contributed towards the development of study period was used as the sampling frame. Based on this
appropriate interventions [43]. sampling frame, computer generated random numbers
were used to select participants waiting to be attended to at
Methods the study site: random numbers were allocated to patients
Study setting and population based on their position in the clinic queue while waiting to
The study was carried out in the largest HIV primary health be attended to by the clinic nurse. This exercise was carried
care clinic in Harare where up to 200 PLWH are seen daily. out while all the patients were in the waiting room waiting
Chibanda et al. BMC Psychiatry (2016) 16:55 Page 3 of 9

to be triaged to nursing evaluation. All those selected were The 9-item Patient Health Questionnaire (PHQ-9) [45]
sensitized, informed briefly about the study before they was the instrument used to screen for probable depres-
were asked if they were willing to participate. All interested sion. The PHQ-9 is amongst the most commonly used
were then given further details of the study and written screening instrument for depression in LMIC [48], and
consent was sought from eligible adults, while those uses a Likert scale giving a score ranging from 0 to a max-
not meeting the criteria outlined above were excluded imum of 27 with each of the 9 items giving a response
at this point. After obtaining written consent the socio- ranging from: Not at all (0); Several days (1); More than
demographic questionnaire and study tools which in- half the days (2); and Nearly every day (3), and a higher
cluded the SSQ-14 [40] and the PHQ-9 [45] were score indicating more severe depression [45]. The PHQ-9
administered by data collectors. It took approximately was validated during the formative stage of the current
15–20 min to administer tools to each participant. study using the structured clinical interview of the diag-
The sample size (N = 264) was chosen to provide good nostic statistical manual (SCID-IV), and showed a sensi-
precision for the primary aim of the validation study, to es- tivity of 84.6 % for depression and specificity of 68.7 %
timate sensitivity and specificity for screening tools against against the SCID at a cut-off of > =11 (results not pub-
the gold standard (SCID), allowing for stratification by HIV lished). We therefore used this validated cut-off score of
status. This sample size enables us to estimate a prevalence 11 and above for moderate depression.
of CMD of 28 % with good precision (95 % CI 22-34 %),
and to have 80 % power to detect odds ratio of 2.5 for an Statistical analysis
exposure which is 50 % prevalent in the controls. Data were entered directly into the study desk-top com-
puter by a data entry clerk using a predesigned data entry
program containing automated range checks, and data
Study measures
cleaning was carried out at the end of each day. Data were
Socio-demographic variables were measured using an
transferred to STATA version 13.0 for analysis. Analysis
adapted locally developed questionnaire previously used
was based on outcome measures of the SSQ-14 for CMD
in similar studies where variables such as unemployment,
and PHQ-9 for depression. Following tests for effect
recent negative life events, poverty and female gender had
modification of HIV status and factors associated with
been found to be associated with CMD [30, 31, 34, 46].
CMD, results were presented stratified by HIV status.
Participants were asked about recent negative life events.
Socio-demographic variables of the two groups (cases vs.
The list of possible negative life events was based on a
non-cases) meeting SSQ-14 and PHQ-9 criteria for CMD
previous study [34] and focus group discussions with both
and depression respectively were initially compared to es-
the lay health workers and participants utilizing a local
tablish differences. Variables with p < 0.15 on univariate
CMD based intervention [44]. These included life events
logistic regression analyses were included in multivariable
such as death in the family, physical assault, sexual assault,
regression, to estimate adjusted odds ratios (OR) and 95 %
forced eviction, an HIV diagnosis, and an illness resulting
confidence intervals (CI).
in admission to a tertiary hospital of either the participant
or an immediate family member.
Results
Characteristics of study participants
Screening tools A total of 332 people were approached during the study
The Shona Symptom Questionnaire (SSQ14) was used as period. Of these 297 (89 %) were eligible, and 264 (89 %)
the primary outcome measure for CMD screening. The of those who were eligible gave consent to take part. Of
SSQ14 is a locally developed 14-item screening tool vali- the 264 included in the study, 208 (79 %) were female and
dated using exemplary cross cultural methods [40]). It 155 (59 %) were married. The majority (237; 89 %) re-
consists of 14 dichotomous questions based on how an ported experiencing a negative life event in the 6-month
individual has been feeling in the past week. It has been period before the study. HIV was highly prevalent, with
used previously in epidemiological studies in Zimbabwe 165 (62.5 %) reported as living with HIV according to self-
[41, 44, 47] and has sensitivity of 96 %, specificity of 83 %, reports confirmed with clinic HIV test records, while 72
and positive predictive value and negative predictive value (27 %) were HIV negative. A total of 27 (10 %) were un-
of 66 and 83 % respectively, using a cut-off of ≥8 [40]. In aware of their HIV status because they had never been
this study population, we found an optimal cut-off score tested. All participants approached were forthcoming with
of > = 9 in a validation exercise carried out by senior doc- their HIV status. Of the 165 who were confirmed HIV
tors in the Department of Psychiatry using the structured positive, almost all (92 %) were on HAART, with most of
clinical interview (SCID-IV) as the gold standard (results these (85 %) on HAART for more than 6 months.
not published - sensitivity and specificity at cut-off of > = 9 Table 1 show characteristics of the study population
were 85.9 and 70.4 % respectively). by HIV status. People living with HIV were more likely
Chibanda et al. BMC Psychiatry (2016) 16:55 Page 4 of 9

Table 1 Characteristics of study participants by HIV statusa

Characteristic HIV positive (n = 165) HIV negative (n = 72) p-value
N % N %
Gender 0.008
Male 41 24.8 % 7 9.7 %
Female 124 75.2 % 65 90.3 %
Age group 0.009
< 30 26 16.1 % 22 32.4 %
30–39 59 36.6 % 28 41.2 %
40–49 56 34.8 % 12 17.6 %
50+ 20 12.4 % 6 8.8 %
Marital status 0.001
Married/steady 87 52.7 % 57 79.2 %
Divorced/widowed 42 25.5 % 4 5.6 %
Single 36 21.8 % 11 15.3 %
Education 0.21
Secondary or more 127 77.0 % 58 80.6 %
Primary or less 38 23.0 % 14 19.4 %
Current employment status 0.78
Unemployed 69 41.8 % 33 45.8 %
Permanent FT or PT 16 9.7 % 7 9.7 %
Casual/self-employed 80 48.5 % 32 44.4 %
Main income source 0.20
Own business/salary 96 58.2 % 35 48.6 %
Partner/family 58 35.2 % 34 47.2 %
No income 11 6.7 % 3 4.2 %
Suffer from chronic illness 0.49
No 86 52.1 % 41 56.9 %
Yes 79 47.9 % 31 43.1 %
Reason for clinic visit 0.02
Routine/family/antenatal 63 38.2 % 39 54.2 %
Other reason 102 61.8 % 33 45.8 %
Negative life events in last six months 0.15
No 13 7.9 % 10 13.9 %
Yes 152 92.1 % 62 86.1 %
SSQ ≥ 9 0.02
No 53 32.1 % 35 48.6 %
Yes 112 67.9 % 37 51.4 %
PHQ ≥ 11 0.002
No 52 31.5 % 38 52.8 %
Yes 113 68.5 % 34 47.2 %
a
HIV status unknown (n = 27) not included

to be female (75.2.% vs 24.8 %; p = 0.008), older (47.2 % Association of probable CMD and depression by HIV status
vs 26.4 % aged ≥40 years; p = 0.009), and divorced/ The prevalence of probable CMD (SSQ14 ≥ 9) and de-
widowed (25.5 % vs 5.6 %; p = 0.001). pression (PHQ9 ≥ 11) were higher among people living
Chibanda et al. BMC Psychiatry (2016) 16:55 Page 5 of 9

with HIV than among those without HIV (67.9 and Zimbabwe have signs of post-natal depression [34],
68.5 % vs 51.4 and 47.2 % respectively; Table 1). On uni- therefore the inclusion of CMD packages of care within
variable analyses, both probable CMD and depression these initiatives is critical as this will contribute towards
were associated with being female, and having experi- improving outcomes for PLWH.
enced negative life events (Table 2). In LMIC the improvement of HAART access will need
On multivariable analyses, female gender and negative to be matched with an equally focused integration of
life events were independently associated with both evidence-based CMD and depression care packages [6]
probable CMD and depression among participants with because there is a large body of data showing that treat-
HIV (Table 3). In addition, there was some evidence that ing CMD among PLWH improves adherence to HAART
probably CMD was associated with having a chronic and quality of life [56–58]. Both HIV positive and HIV
medical condition (OR = 1.87, 95 % C I 0.92–3.81) and negative women are more likely to be affected by CMD
that depression was associated with having less than sec- and depression in our setting [29, 34]. Furthermore they
ondary education (OR = 3.68, 95 % CI 1.35–10.07). The are more likely to utilize primary health care facilities
small number of HIV negative participants reduced the than their male counterparts [59]. Therefore focusing on
ability to look at associations in this group, but there women who are living with HIV at primary health care
was some evidence that females were at higher risk of level, particularly those with negative life events who
probable CMD (OR = 3.05, 95 % CI 0.51–18.12) and screen positive on the SSQ-14 and PHQ-9 will strengthen
stronger evidence that less than secondary education existing HIV related programs such as the PMTCT and
and negative life events were associated with depression the newer Option B+. There is evidence showing the feasi-
(OR = 5.69, 95 % CI 1.26–25.7 and OR = 9.42, 95 % CI bility of using screening tools at primary health care level
1.36–65.1, respectively) in Zimbabwe [34, 41, 44, 60] but these tools are not inte-
grated into HIV care programs.
Discussion There are several psychological interventions that have
We found a high prevalence of probable CMD and de- been shown to work in LMIC, which could be adapted
pression (both over 60 %) among PLWH, underpinning for use among PLWH [61–64]. However, most of the
the importance of detecting and addressing common studies evaluating the effectiveness of these interventions
mental disorders in this population. Our results indicate for PLWH have been of poor quality [25]. Therefore
that probable CMD and depression in PLWH, as mea- there is a need to conduct rigorous formative research
sured by the SSQ-14 and the PHQ-9, are associated with to design interventions and evaluate them before they
recent negative life events and female gender. These are introduced or integrated into health care facilities in
findings reflect those from non-HIV infected popula- LMIC. Part of this process should involve establishing
tions [29–31, 49]. In a recent systematic review of factors that are associated with CMD and depression,
screening tools used in LMIC, prevalence of 11 %–55 % and using this information to determine the content of
was reported, however, none of the studies looked at interventions for specific populations. Our findings sup-
HIV populations on ART [48]. While the risk of false port the use of a problem solving therapy approach
positive screening results from self-report measures is a because of the strong association between negative life
concern, such tools can contribute towards identifying events and CMD [65]. Problem solving therapy has shown
those most at risk of CMD in resource-poor settings promising results in earlier pilot studies in Zimbabwe,
when validated and used within primary health care fa- particularly among participants who have experienced
cilities [6, 7]. negative life events [44, 61]. It guides participants through
Although we did not measure adherence to HAART a process to list the problems (negative events) that they
in our study population, there is growing evidence of an face, select a problem to tackle based on the client’s prior-
association of CMD and depression with poor adherence ities, develop a specific and measurable way of addressing
to HAART [8, 50, 51]. There is also evidence suggesting the problem and execute an action plan aimed at address-
that treatment of depression increases adherence to ing the problem while motivating and encouraging the
HAART [50, 52]. Despite being on HAART, PLWH face participant to be pro-active in the process [44].
a magnitude of problems and are twice as likely to suffer There is evidence supporting the use of lay health
from depression when compared to HIV negative matched workers to deliver such interventions for CMD in LMIC
controls [34, 53, 54]. The findings of our study have impli- [24] with a number of well designed randomized con-
cations for some of the newer WHO initiatives such as the trolled trials suggesting that this is a cost-effective way
Option B+ [55] which advocate for immediate commence- of addressing the treatment gap for MNS [21, 66–68].
ment of HAART for HIV infected pregnant women. Over Our study’s main limitation is the lack of data on HIV
30 % of women attending the Prevention of Mother to staging and viral load markers. These factors can be
Child Transmission of HIV (PMTCT) program in associated with increased risk of developing CMD and
Chibanda et al. BMC Psychiatry (2016) 16:55 Page 6 of 9

Table 2 Characteristics of HIV + participants by SSQ-14 and PHQ-9 scores

SSQ ≥ 9 PHQ ≥ 11
Univariable analysis Univariable analysis
Total N % OR 95 % CI p-value Total N % OR 95 % CI p-value
Gender 0.03 0.05
Male 41 53.7 % 1.00 - 41 56.1 % 1.00 -
Female 124 72.6 % 2.29 (1.10–4.74) 124 72.6 % 2.07 (1.00–4.31)
Age group 1.00 0.66
< 30 26 69.2 % 1.00 - 26 65.4 % 1.00 -
30–39 59 67.8 % 0.94 (0.35–2.53) 59 69.5 % 1.21 (0.45–3.21)
40–49 56 67.9 % 0.94 (0.34–2.56) 56 66.1 % 1.03 (0.39–2.74)
50+ 20 70.0 % 1.04 (0.29–3.69) 20 80.0 % 2.12 (0.54–8.26)
Marital status 0.75 0.37
Married/steady 87 65.5 % 1.00 - 87 66.7 % 1.00 -
Divorced/widowed 42 69.0 % 1.17 (0.53–2.59) 42 64.3 % 0.90 (0.42–1.95)
Single 36 72.2 % 1.37 (0.58–3.21) 36 72.8 % 1.75 (0.71–4.32)
Education 0.93 0.01
Secondary or more 127 67.7 % 1.00 127 63.8 % 1.00
Primary or less 38 68.4 % 1.03 (1.45–3.04) 38 84.2 % 3.03 (1.18–7.79)
Currently working? 0.53 0.86
Unemployed 69 71.0 % 1.00 - 69 69.6 % 1.00 -
Permanent FT or PT 16 56.3 % 0.52 (0.17–1.60) 16 62.5 % 0.73 (0.23–2.57)
Casual/self-employed 80 67.5 % 0.85 (0.42–1.71) 80 68.8 % 0.96 (0.48–1.93)
Main income source 0.51 0.17
Own business/salary 96 65.6 % 1.00 - 96 65.6 % 1.00 -
Partner/family 58 69.0 % 1.16 (0.58–2.34) 58 69.0 % 1.16 (0.58–2.34)
No income 11 81.8 % 2.36 (0.48–11.55) 11 90.9 % 5.24 (0.64–42.70)
Chronic medical condition 0.07 0.33
No 86 61.6 % 1.00 - 86 65.1 % 1.00 -
Yes 79 74.7 % 1.84 (0.94–3.58) 79 72.2 % 1.39 (0.72–2.69)
Suffer from other chronic illness 0.75 0.43
No 127 68.5 % 1.00 - 127 66.9 % 1.00 -
Yes 38 65.8 % 0.88 (0.41–1.91) 38 73.7 % 1.38 (0.61–3.11)
Negative life events 0.004 0.02
No 13 30.8 % 1.00 - 13 38.5 % 1.00 -
Yes 152 71.1 % 5.52 (1.62–18.87) 152 71.1 % 3.93 (1.22–12.67)
ARV medication 0.35 0.12
No 14 78.6 % 1.00 - 14 85.7 % 1.00 -
Yes 151 66.9 % 0.55 (0.15–2.06) 151 66.9 % 0.34 (0.07–1.56)
Disclosure to partner 0.78 0.44
No 69 66.7 % 1.00 - 69 65.2 % 1.00 -
Yes 96 68.8 % 1.10 (0.57–2.13) 96 70.8 % 1.30 (0.67–2.51)

depression [69–71]. Although similar high rates of reduces the generalizability of our findings. Further-
CMD and depression have been reported from other more, the use of screening tools without a gold stand-
LMIC [6, 72], the use of a clinic-based sample of people ard to confirm diagnosis may result in the inclusion of
predominately visiting the clinic for physical ailments participants who are not actually clinically depressed
Chibanda et al. BMC Psychiatry (2016) 16:55 Page 7 of 9

Table 3 Multivariate analysis of factors associated with probable need to introduce interventions within HIV care clinics
CMD and depression among participants with HIV at primary health care level aimed at addressing this
Probable depression CMD Adjusteda OR 95 % CI p-value burden, which if left unchecked could negatively impact
(SSQ > = 9) the gains made in the fight against HIV/AIDS in the last
Gender 0.04 2 decades. We further recommend the use of a two-
Male 1.00 stage screening process particularly where resources are
Female 2.32 (1.07–5.05) scarce to avoid the inclusion of false positives, with the
Chronic medical condition 0.09
second stage consisting of a diagnostic screen. However,
in resource-poor settings with large numbers of LHWs a
No 1.00
greater sensitivity and a lower specificity would be rec-
Yes 1.87 (0.92–3.81) ommended to ensure that all possible cases are included.
Negative life events 0.03 We further recommend that the Option B+ program be
No 1.00 administered with a psychological intervention. Further
Yes 4.14 (1.17–14.69) studies are needed to look into the development of
Depression (PHQ > = 11)
multiple stage screening delivered by LHWs.
Gender 0.12 Competing interests
Male 1.00 - All the authors declare that they have no competing interests.

Female 1.84 (0.85–4.02) Authors’ contributions

Education 0.01 DC Study design, developing first draft and preliminary analysis of data review of
subsequent drafts leading to final manuscript. FC Study design, review first and
Secondary or more 1.00 - final draft. LG Analysis of data. HW Sampling strategy, statistical analysis, review
Primary or less 3.68 (1.35–10.07) first draft and third draft. CL Study design, review all drafts leading to final
manuscript. All the authors read and approved the final version of the manuscript.
Negative life events 0.02
No 1.00 - Acknowledgement
Staff at Edith Opperman Polyclinic Mbare for continued support of the
Yes 4.93 (1.31–18.50) Friendship Bench initiative, Percy Taruvinga, Tarisai Bere, for training of LHWs
a
adjusted for other factors in the table and translating documents. Ronald Munjoma, Epiphania Munetsi, and Ethel
Manda for coordinating the recruitment and data collection. This study was
supported through a Grand Challenges Canada (GCC) grant.

[73]. Nevertheless, our cut-off score was based on a val- Author details
1
University of Zimbabwe, College of Health Sciences, Mazowe Street, P.O Box
idation study conducted in Zimbabwe and provide an A178, Harare, Zimbabwe. 2University College London, Gower Street, London
indication of the likely margin of error on these mea- WC1E6BT, UK. 3MRC Tropical Epidemiology Group, London School of
sures. Studies utilizing clinical interviews have found Hygiene and Tropical Medicine, Keppel Street, London WC1E7HT, UK.
4
Department of Psychiatry and Mental Health, University of Cape Town, Alan
lower rates but these are still higher than those found J Flisher Center for Public Mental Health, Cape Town, South Africa.
in non-HIV infected people [7]. In addition, data on the
type of HAART being taken by study participants was Received: 28 October 2015 Accepted: 24 February 2016
not available. A number of HAART drugs can increase
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